State v. Royal

1

STATE OF MISSOURI, Respondent, v. NANCY J. ROYAL, Appellant.

No. WD85680

Court of Appeals of Missouri, Western District, Special Division

October 22, 2024

APPEAL FROM THE CIRCUIT COURT OF LIVINGSTON COUNTY, MISSOURI THE HONORABLE RICHARD BRENT ELLIOTT, JUDGE

Before: Alok Ahuja, Presiding Judge, Mark D. Pfeiffer, Judge and W. Douglas Thomson, Judge

W DOUGLAS THOMSON, JUDGE

Nancy Royal appeals from the trial court's judgment convicting her of first-degree involuntary manslaughter, child neglect resulting in death, child abuse, and two counts of first-degree endangering the welfare of a child following a jury trial. Royal was sentenced to a total of 30 years' imprisonment. She brings three points on appeal. First, Royal argues there is insufficient evidence that she knowingly neglected her child and caused his death. Second, she argues there is insufficient evidence that she knowingly abused her other minor child by failing to educate her. Finally, Royal argues the trial court plainly erred in convicting her of both involuntary manslaughter and child neglect resulting in death because her simultaneous conviction of both offenses violates Missouri's cumulative punishment statute. Finding no error, we affirm.

I. FACTUAL AND PROCEDURAL HISTORY^[1]

We begin with a brief account of the startling facts of this case before commencing a detailed description of the evidence.

J.R.^[2] was 11-years old and weighed 36 pounds when he died on February 9, 2019. He was 59 inches nearly 5 feet tall, the day he died. J.R. had not seen a doctor since he was 22 months old, when he weighed 28 pounds. A pediatrician who reviewed the case stated that J.R. "looked like he came from a concentration camp, he was that thin." Police and paramedics discovered J.R. unresponsive -without a pulse and not breathing - on a bed after responding to a 911 call made regarding him. Based on his size, they estimated J.R. was approximately 6 years old. First responders testified to seeing "black" fluid resembling "coffee grounds" around J.R.'s mouth, on his clothes, and on the bedding around him that was later determined to be blood from his stomach. First responders who performed CPR on J.R. observed both the black fluid and a yellow foam coming from J.R.'s nose and mouth. After being pronounced dead at a hospital, an autopsy of J.R. determined his cause of death was diabetic ketoacidosis complicated by acute influenza. J.R. died wearing soiled, dirty clothes.

J.R. was Royal's son. Royal resided in the home with J.R.

V.R. was 9-years old when police officers encountered her in the home. Despite her age, V.R. told officers that she did not know the alphabet. She had never been to school. She could not read or write. V.R. told officers she did not know when her birthday was. She did not have a toothbrush.

V.R. was Royal's daughter. She resided in the home with Royal and J.R.

The house smelled strongly of urine and feces. Officers obtained and executed a search warrant and found piles of both animal and human feces throughout the house. One closet appeared to be used as a toilet and was full of feces and urine. The kitchen contained dirty dishes and old and rotting food. The house was so dirty that the Children's Division investigator who responded to the home to interview V.R. had to step outside to be sick.

Because Royal challenges the sufficiency of the evidence for both Count II (child neglect resulting in J.R.'s death) and Count III (child abuse for failing to educate V.R.), we must set out the grim details which comprise the factual record.

A. J.R.'s illness and death

In the week leading up to J.R.'s death, most of his family contracted the flu. Each of the family members, including J.R., managed their flu symptoms at home without seeing a doctor. J.R. started experiencing flu-like symptoms on February 6, 2019. J.R. was sick for approximately three days before he passed.

V.R. testified at length about J.R.'s illness leading up to his death. According to V.R., Royal was either sleeping in her room or drinking vodka while J.R. was sick. V.R. stated that J.R. "had been sick for a really long time" and "that he begged for something to eat and especially begged for soda." V.R. also stated that food and soda would make J.R. "sicker" so her parents would not give him food or soda. J.R. "kept throwing up this weird, like, blackish stuff, and sometimes he would throw up, like, this red stuff." J.R. could not get up to go to the bathroom and would soil himself in the bed. No one changed the sheets. V.R. would sometimes help J.R. to the bathroom. J.R.'s older brother testified that he also helped J.R. to the bathroom while he was sick. J.R. also told V.R. shortly before he died that he was unable to hear. V.R. also saw J.R. speak to someone who was not there before he died. Shortly before J.R. died, he lost the ability to speak.

Royal testified that she was unaware that J.R. was so sick that he was unable to walk. This, despite the fact that Royal had previous training as a certified nursing assistant. Royal believed she could effectively manage J.R.'s illness at home. She discovered J.R. was not breathing in the early morning hours of February 9, 2019 and began CPR. Royal's husband called 911, but V.R. stated that Royal was unhappy that emergency services had been contacted and stated, "I don't want them to come. I can handle it."

First responders, including police, arrived at the Royals' residence around 3:30 a.m. on February 9, 2019. They smelled alcohol coming from Royal. Royal and her husband both acknowledge that Royal is an alcoholic. Royal's husband described her as "belligerent" toward the first responders who were tending to J.R. Royal was uncooperative, angry, and loud with police officers who responded to the scene. Royal did not immediately leave to follow J.R. to the hospital, despite repeated urges from first responders, and did not arrive at the hospital until an hour and a half after J.R. was taken by ambulance.

An autopsy was performed on J.R., which revealed he died of diabetic ketoacidosis complicated by acute influenza. First responders had tested J.R.'s blood glucose levels when assessing him and found his glucometer reading was over 600. The glucometer used by first responders does not give readings above 600, so J.R.'s exact blood glucose level is unknown.

Three experts testified at Royal's trial about J.R.'s medical condition and cause of death. The State offered a pediatrician ("State Pediatrician") and the medical examiner who conducted J.R.'s autopsy ("Medical Examiner"). Royal offered her own expert: a pediatrician and pediatric infectious disease doctor ("Defense Pediatrician").

State Pediatrician

The State Pediatrician works with the State Technical Assistance Team (STAT), which investigates allegations of child abuse. The State Pediatrician had worked his entire career in pediatrics, including diagnosing children with Type I diabetes. He estimated that in his career, he had diagnosed "well over a hundred, and probably close to 200" children with Type I diabetes. The State Pediatrician reviewed the following records relating to J.R.'s death the police report, the EMT/paramedic report from the 911 call through the arrival at the hospital, all of J.R.'s records from Pershing Memorial Hospital in Brookfield, which included a visit at 22 months old and the visit where he died, the postmortem report from the doctor who performed J.R.'s autopsy, photographs taken during the investigation at J.R.'s home, photographs taken during J.R.'s autopsy, and photographs taken during J.R.'s hospitalization where he was pronounced dead.

The State Pediatrician testified at length about Type I diabetes. Type I diabetes presents in several ways, but "typically children are well and then they get a minor viral illness, an upper respiratory infection, a little GI bug ... [a]nd kids go from literally being well to critically ill within two or three days typically." When a child with undiagnosed Type I diabetes contracts a minor illness, including the flu, their immune system creates antibodies to kill the germs making them sick and "in that manufacturing process.an autoantibody is formed incorrectly and it attacks the body's pancreas.where our insulin is made." Children with Type I diabetes can also present with the "three P's," which the State Pediatrician described as (1) polyphagia (increased hunger without gaining weight), (2) polydipsia (increased thirst), and (3) polyuria (increased urination).

Children with undiagnosed Type I diabetes can experience weight loss -typically between 10 and 12 percent of their body weight. Any more weight loss is considered "rapid" and "is going to cause shock in the system and ultimately a cardiovascular collapse." Children diagnosed with Type I diabetes must monitor and manage the condition for the rest of their lives, and often spend time in the hospital after they are diagnosed to learn to manage the condition. With proper management, those with Type I diabetes "can live well on into adulthood."

The State Pediatrician also testified about the importance of regular "well checks" during childhood. The standard schedule for well checks is, according to the child's age: two weeks, one month, two months, four months, six months, nine months, 12 months, 15 months, 18 months, 24 months, 30 months, 36 months, and then yearly after the child's third birthday. In a child's first two years, their pediatrician is tracking their weight development, screening for various chronic conditions, and providing immunizations. According to the State Pediatrician, "growth is our most sensitive parameter that we follow for good health." "If we see a child dipping down on the growth curve, that...